Essential skills for pain clinicians

Strangely enough I don’t have a specific reading or paper for my post today – only my experience over a long time working in pain management. Now I know anecdotes are not strong evidence, yet at the same time there are some things that have yet to be well researched, so this is an attempt maybe to put something out there that someone will pick up and run with!

What are some of the essential skills for pain clinicians?

Whether they’re working in acute pain or chronic pain, I think the first and sot essential skill is the ability to listen and be empathic towards the peson with pain. To me, listening with the whole mind and heart is a clinical imperative. It means really hearing what the person is saying with words and body.

Why would I put this skill at the top of the list?
Well, because pain is something we all know about, and experience ourselves, sometimes I think we can forget that the pain we feel is not the same experience as another person.

Listening means we start to understand the critical questions for effective treatment: why has this person come to this place at this time?

Because having pain doesn’t inevitably lead to a person coming for treatment, something we really need to understand is what triggered this person to decide that their pain is significant enough to need treatment? While the intensity and quality if the pain is associated with seeking treatment, many people look for help when their pain isn’t so intense, while still others wait with quite high levels of pain and only go to see someone because of ‘something else’.
That ‘something else’ might be a worry that the pain isn’t disappearing, or that the pain is a sign of something sinister, or because their partner is worried, or because they are feeling exhausted or distressed, or because their case manager decides they need to see someone…

The reason someone comes in for treatment ties closely to their expectations for treatment. If a person is coming hoping to find a cure, an explanation, a way to have better sleep, relief from the worry that it’s something sinister – all of these mean quite different things are required from your intervention.

The second essential skill for clinicians working in pain management is the ability to pull information from multiple domains, then organise that information to help develop a good picture of the many factors that lead the person to have the problems with their pain that they do have. It ties in well with the first skill, and to the ability to match the person’s expectations for treatment.

This skill relies on several sub-skills – listening is one of them, but so is the ability to recognise our cognitive biases. Those things our brains do to help make life easier can trip us up when we’re trying to form a broad understanding of the things that are influencing the person’s presentation. What I mean by this is that we have biases that make it easier to forget information that comes after the first information. We tend to find patterns even when there are none. We recall what has gone before – but selectively, so we’ll remember a patient that reminds us of the person we are talking to now; we’ll recall that last new journal article we read; we’ll remember the things that went well but probably forget the little things that didn’t go so well. When we’re trying to assemble information about a person’s pain we would do well to have a systematic way to collect the information so we don’t jump to conclusions or search for information that confirms what we think we know!

Another subskill for the ability to draw information from multiple sources is to be up-to-date on what is coming through from the research, and to be able to let go of old and out-dated rules of thumb, and start to pick up on new evidence. This is really hard because our brains have trouble ‘letting go’ of well-used information. For example, it has been a challenge for me to attend more to information about pain-related anxiety and neglect of a CRPS limb rather than posture.

A final subskill for drawing information from multiple sources is to work with a team, and appreciate the contribution of other clinicians. To move from a unidisciplinary approach to an interdisciplinary approach requires skills that many of us haven’t been trained in – things like recognising that other disciplines value and see aspects of the person’s presentation as more important than the ones we may have been trained to prioritise, to learn the language of other professions, and to know when it’s time to either stand up and emphasise something, or stand back so other things can be emphasised.

Actually, I think this last skill is one that is in itself essential for pain clincians. Especially as we learn more about how acute pain can become chronic disability, teamwork has become far more essential for effective pain management. It’s so important for the person who has pain to know that all the people working to help him or her function well are aware of each other, give consistent information, use consistent strategies, and have the same aims.

The final essential skill for clinicians is to have a good, basic description of pain. And not to confuse a description of pain with a diagnosis of the underlying disorder – these are not the same thing! While a diagnosis can help in the ongoing management of pain, it is so important that clinicians can talk about what pain is – covering the biopsychosocial aspects of it, being able to describe the functional aspects of neurobiology – explaining that pain is ALL in the brain, and the brain is simply signalling that THIS IS SOMETHING TO NOTICE – whether it’s an ‘issue in the tissues’ or an echo of something past, prediction of some danger in the future, or something else – this keeps the clinician aware of what is really going on (and reduces the chance that he or she gets swept up in the search for ‘the diagnosis’ without remembering the person who is experiencing the pain), and helps the person with pain realise that he or she can do something to help.

These essential skills are not exclusive – they’re just my attempt to shine the light on some of the critical skills that have helped me, and the skills I’ve seen others use successfully. Because as we know, it’s not just the ability to know the literature, it’s how we use the information that is so important – and that part is perhaps the only part I’ll agree is ‘art’ in science.

4 comments

I agree totally. It is so important to know why your patient has come now. It is important to gather information on the bothersomeness of the pain. What it is doing to this person;s life as this is so important and perhaps more important than the pain itself as often we cannot change the pain but rather the quality of life for that person. I use the ICF to ensure I cover all things for chronic pain and I teach my physio students to use this model as well.

That’s so good to hear – ICF is something I’ve struggled with, a bit, to learn – but I can see how applicable this is in pain management. My only query about focusing on QoL alone is that it’s also important to know the underlying elements that are limiting: while pain intensity isn’t often able to be changed, attitudes towards it are. I worry that for some professionals (and I’m not thinking of physiotherapy here) a focus on QoL may lead them to suggesting adaptive technology and techniques that, while they may increase participation, may not address the reasons people are not engaging in those things.
For example, in the rush to ensure someone can get out and into the community, a woman I saw had been provided with a wonderful swivel seat for her car, and she had all the modifications to her home that anyone could want. She could *do* her ADL’s, get out into the community, but was incredibly fearful of her pain and was gradually reducing her ability to do things without adaptations. Despite having the swivel seat for her car, she couldn’t go out to a restaurant or go to a movie because no-one had thought about whether she could sit on the chairs! And I really fail to see that it’s useful to then modify every environment to be ‘inclusive’ for her needs when this would mean modifying the environment for every individual difference!
Oh if only someone had assessed *why* she was not doing activities, and had gone beyond her initial self-report that ‘it’s the pain, it’s the pain that stops me’ and started to explore her beliefs *about* the pain, she would have been far more independent, and far less restricted in her engagement in the real world.
Sorry, this is probably off-topic, but I have been pondering the difficulty between short-term and long-term satisfaction with treatments and life goals – sometimes people coming to a pain management centre really want short term distress reduction rather than developing longterm coping strategies that take hard work! Maybe the topic of another post!
Thanks for taking the time to comment, I really do appreciate it – you make me think!
cheers
Bronnie